=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255413506
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HUDSON DENTAL ESTHETICS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5300 BERGENLINE AVE SUITE 8
-----------------------------------------------------
City | WEST NEW YORK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07093-5616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-865-7750
-----------------------------------------------------
Fax | 201-865-3299
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5300 BERGENLINE AVE
-----------------------------------------------------
City | WEST NEW YORK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07093-5616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-865-7750
-----------------------------------------------------
Fax | 201-865-3299
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL NOURBAKHSH
-----------------------------------------------------
Credential | D,D,S
-----------------------------------------------------
Telephone | 201-865-7750
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI01924600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------